Combination Treatments for Infertility

NEW YORK, Jan 20 (Reuters Health) -- Women who undergo induction of superovulation -- stimulation of the ovaries with a drug to produce several eggs -- followed by intrauterine insemination -- injection of sperm into the uterus -- are more likely to become pregnant than those who undergo artificial insemination alone, according to a report in the January 21st issue of The New England Journal of Medicine.

Dr. Sandra Ann Carson of Baylor College of Medicine, Houston, Texas, and associates estimate that the chance of pregnancy is 3.2 times higher for women who undergo the combined procedure than for those who undergo intracervical insemination -- injection of sperm into the cervix -- and 1.7 times higher than for women who undergo intrauterine insemination without superovulation.

The combination procedure is commonly performed in the US, but Carson's team says that theirs is the first large-scale scientific study to scrutinize its effectiveness.

The investigators studied 932 couples who had been infertile for more than 1 year. All female partners were 40 years of age or younger and had no reproductive abnormalities. All male partners had at least some sperm that were capable of moving.

Each couple was randomly assigned to undergo up to four cycles of one of four treatment procedures: superovulation and intrauterine insemination, superovulation and intracervical insemination, intrauterine insemination alone, or intracervical insemination alone.

The pregnancy rate was highest (33%) among the couples treated with superovulation and intrauterine insemination, and lowest (10%) in the couples treated with intracervical insemination alone, Carson and her colleagues report.

The research team found that the chance of a live birth, as opposed to a miscarriage or a tubal pregnancy, was higher in the two groups treated with superovulation than in the groups treated with artificial insemination alone.

But women assigned to the two superovulation groups had a high rate of multiple pregnancies (30%), "with a rate of triplet and quadruplet pregnancies of almost 9%," according to an accompanying editorial by Drs. Egbert R. te Velde and Bernard J. Cohlen, of University Hospital Utrecht in the Netherlands.

Cohlen and te Velde recommend that superovulation and intrauterine insemination should be the first option for infertility treatment only if "the stimulation protocol is mild, the cycle is carefully monitored, and there are strict criteria for the cancellation of treatment to avoid hyperstimulation and multiple pregnancy."

When infertility is due to the male partner's low sperm count or low sperm mobility, the editorialists advise, "treatment should be restricted to intrauterine insemination alone, because induction of superovulation has little additional effect."

Cohlen and te Velde emphasize that "treatment of infertility usually does not make the difference between conceiving and not conceiving; the difference lies in conceiving sooner rather than later."

"The risks of the 'sooner' option in terms of multiple pregnancy, ovarian hyperstimulation syndrome, emotional stress, and financial costs may be unacceptably high," they add.

"The marketing of assisted reproductive technology should include realistic perspectives instead of hyperstimulated illusions," the Dutch editorialists conclude.

SOURCE: The New England Journal of Medicine 1999;340:177-183, 224-226.